Introduction

A gold standard simulation involves a well-planned, well-executed scenario.  An ideal or gold standard simulation scenario includes embedded participants (EPs) to portray roles in the scenario that are not designated as the patient or the learners.  It is usual practice for a group of learners to alternate or take turns being the learner in one scenario, and then being an embedded participant in another scenario. These EPs are sometimes referred to colloquially as hot seat participants. The Healthcare Simulation Dictionary is a Society for Simulation in Healthcare (SSH) publication that defines simulation terminology.  Although hot seat participant is not included, the term embedded participant (EP) is defined as: "An individual who is trained or scripted to play a role in a simulation encounter to guide the scenario, and might be known or unknown to the participants; guidance may be positive or negative, or a distractor based on the objectives, level of the participants, and the needs of the scenario" (Lioce et al., 2020, p. 16).

Historically, the term used to describe the role of EP was confederate. The Victorian Simulated Patient Network defined confederate as: "An individual other than the patient, who is scripted in a simulation to provide realistic experiences, simulate challenges, or additional information for the learner, e.g., paramedic, receptionist, family member, laboratory technician" (Lioce et al., 2020, p. 12). The Australian Society for Simulation in Healthcare defined confederate as: "An individual(s) who, during the clinical scenario, provides assistance locating and/or troubleshooting equipment. This individual(s) may provide support for participants in the form of 'help available,' e.g. 'nurse in charge,' and/or provide information about the manikin that is not available in other ways, e.g., temperature, color change, and/or to provide additional realism by playing the role of a relative or a staff member" (Lioce et al., 2020, p. 12).  As of today, the term embedded simulation personnel (ESP) is considered the most politically correct and most up to date simulation term to describe this role. Even so, you may still find old and new literature that includes the terms EP, confederate, standardized patient, simulated patient, simulated person, role player, or actor.   

In a 1993 Academic Medicine publication, HS Barrow recalled how, in the 1960s, he first defined the term standardized patient (SP), which per his definition, included either a simulated patient or an actual patient with specialized training. H[1]S Barrow was one of the early adopters of SPs in healthcare simulation education and helped develop the role in academic medicine. The use of SPs has grown since the 1960s and is now ubiquitous.  Sometimes an SP is enlisted to play the role of an ESP in a high-stakes/summative simulation scenario. The authors further define a standardized patient to be a person who is coached/trained to simulate a patient so accurately that a skilled clinician cannot detect the simulation.  For both learner assessment of performance and provider assessment of the quality of care, SPs have been utilized as undercover, mystery, or incognito simulated patients/clients.[2][3][4] Standardized patients are paid and often charge by the hour, sometimes with a minimum number of hours required at the time of booking.[5]

Other times, a learner-volunteer is asked to step into the ESP role in low-stakes/formative simulation scenarios.  The authors further define embedded simulation personnel (ESP) as an individual who is trained or scripted to play a role in a simulation encounter to guide the scenario and may be known or unknown to the participants.  ESPs are often volunteers or unpaid, creating the term volunteer embedded participant (VEP). On occasion, VEPs may be given a gift for their participation and/or have costs covered, such as parking and lunch.[5]

Function

According to Sanko et al., a confederate is "among the most powerful tools available to simulation instructors".[6] This is because a confederate/ESP plays a substantial role in the determination of the psychological or emotional fidelity of a simulation scenario. Therefore, simulation instructors achieve the highest level of realism/fidelity by using properly trained ESPs, which one could argue is equivalent to a paid SP in the ESP role.  Sanko et al. go on to define how theater arts and the study of theater can apply to healthcare education simulation, which is an aspect often overlooked by healthcare simulation educators. 

To optimally use ESPs, they must be informed with comprehensive knowledge of the scenario, learning objectives, assessment tools, and a full simulation scenario script. ESPs must receive training on their role, be attuned to the level of learners in the simulation, and be cognizant of the intended impact on learning outcomes.  When educators design scenarios, consideration should be given to the roles of ESPs and how best to utilize them.  Simulation educators should also develop full scripts for each ESP and also permit the simulationist running the scenario to make changes on the fly to achieve the learning objectives.[5]  

Best-practices for utilization of ESPs are echoed in the Pascucci et al. publication that described their 10-year experience recruiting and training SPs for use as ESPs and other simulation roles at Boston Children's Hospital.[7] Pascucci et al. listed guidelines and necessary information to provide SP actors as deliverables that simulation scenario designers should construct during scenario development:

• Learning objectives
• Level of experience and training for learners/participants
• Duration of the scenario, including ways to end/stop authentically
• Clearly written medical details
• Glossary of medical terms and relevant background medical information
• Age
• Sex, including gender identity
• Socioeconomic status
• Family dynamics
• Emotional states of patients and families in similar situations
• Examples of typical comments, questions, or concerns expressed by patients and family members.[7] 

To meet these guidelines, ESPs need training and dress rehearsal sessions before running a simulation scenario with learners present.  These pre-scenario events represent current best practices in simulation education and the use of ESPs.[5]  

Jill S. Sanko is also the first author of Using Embedded Simulated Persons, a chapter in the SSH book Defining Excellence in Simulation Programs. Sanko et al. stated, "...simulation programs that lack training and assessment of ESPs do their learners and their programs an injustice, robbing them of the full spectrum of engagement and learning that can take place in a well-rehearsed, well-rounded, and well-acted simulation experience" (Sanko et al., 2015).  The chapter listed ten recommendations to improve the use of ESPs:  

1. Do allow learners to make mistakes: There is no better setting for errors than simulation.
2. Do not ad-lib for drama's sake: There's a time and a place, for, but it is not usually in simulation.
3. Do adapt to learner behaviors: The scenario should be scripted, but learners' responses are unpredictable.
4. Do use communication devices: They help keep ESPs and scenario coordinators on track but beware of their pitfalls.
5. Do know your learners: Their level of training should guide the ESPs' words and actions.
6. Do use realistic props and costumes: They always tell a story and provide valuable clues.
7. Do commit to the character: ESPs are playing roles to send messages to the learners, not playing themselves.
8. Do pay attention to nonverbal cues: Emotional responses contribute to learning.
9. Do not be the star of the show: Simulation is all about the learners' improvement.
10. Do find ways to improve: Rehearse before, debrief, and evaluate after simulation.

Adler et al. showed that ESP training is essential and can be done well when following the above guidelines and recommendations.[8] In the CPR CARES study, they used two ESPs, who were cross-trained to play two roles, provided pre-scenario practice sessions, and supplied pocket cards and materials intended for review just before running the simulation scenarios. Simulation educators then conducted a real-time rating of the ESPs' performance of learner interaction and role-play during the simulation scenarios. Researchers demonstrated the method of training ESPs resulted in 85% of ESPs achieving a perfect rating on the checklist.[8] Ballas et al. demonstrated the successful use of ESPs in all roles other than the surgeon for a surgical curriculum designed to teach emergency undocking during robotic surgery.[9]  

Issues of Concern

Cheng et al. proposed two formats for designing simulation scenarios to practice crisis resource management (CRM).[10]  One involved running CRM scenarios with learners and ESPs with the assumption that at some point in the scenario, CRM principles will present, which will subsequently be discussed and addressed during debriefing.[10] The other format involved careful scripting of all roles and designing scenarios to include specific CRM principles.[10] 

This suggests that specific scenarios and educational goals, such as CRM training, may not require such scripted, practiced, trained ESPs to achieve learning objectives. In 2015, Bosse et al. tested the effectiveness of medical student peer role-play (i.e., embedded participants) versus formally trained SPs in a communication scenario designed for summative assessment of medical students via objective structured clinical exams (OSCEs).

Researchers found comparable OSCE performance levels in both groups of medical students using the Calgary-Cambridge Referenced Observation Guide. Additionally, a cost-effectiveness analysis showed that medical students strongly favored peer role-play over trained SPs.[11] This was in follow-up to a 2010 study from the same group of educators who found that medical students indicated a preference for the use of SPs for communication training while both groups (peer role-play versus trained SPs) demonstrated student achievement/learning.  Educators also noted the potential for role-playing to foster greater empathy among students.[12] There is support in the nursing education literature for the use of role-playing to teach communication and patient-centered care.[13][14][15]

These studies cited the need to have carefully designed sessions and training for the role-playing students, which may resolve any skepticism regarding the usefulness of role-playing. There is also support for achieving learning objectives through the use of role-playing in undergraduate medical education.[16][17][18][17]    

A 2005 review of the literature on the topic of SPs versus peer role-play concluded there was a definitive need for well-designed studies to assess communication skill acquisition in various educational settings.[19] Yet as of 2020, there are only a few studies and no definitive answers. A 2015 pilot study compared post-interview perceptions of physical therapy students who interviewed SPs versus volunteer patients and found students in both groups found the experience equally useful.[20] 

Both the volunteer patients and the SPs had a 30-minute orientation to go over the purpose, timing, and format of the interview.  Both groups were encouraged to answer questions but not provide more detail, thus requiring students to ask more questions. The cost for SPs in this study was three times that of the volunteer patients, and therefore the conclusion was volunteers are more cost-effective. There are also instances in the literature where the knowledge pertinent to specific/specialized skill sets have known limitations, such as the use of trained SPs for the role of physician anesthesiologists in high-fidelity surgical simulations.[21] 

If the fidelity of surgical simulation and achievement of learning objectives depends on the realistic depiction of anesthesiologists, a highly-trained physician with a particular skillset, then utilization of actual anesthesiologists could be both essential and more cost-effective versus trained SPs.  

Curriculum Development

Given that current simulation education literature supports the use of role-playing, volunteer patients, and standardized patients as ESPs, educators must judge which will be the best fit for their educational goals, learner groups, and budget.  Formative learning may be a better fit for the more cost-effective peer role-players and VEPs. Summative high-stakes testing environments or high-level simulation research may require the use of specially trained SPs to play ESP roles.[22] 

While peers are readily available for role-playing, volunteers may not be as invested in the simulation learning as paid SPs. Literature does not mention this when discussing the use of volunteers, so this concern may be mitigated by careful selection of VEPs such that they are also invested in the learning objectives. Studies indicated equal educational quality and achievement of learning objectives in all groups: role-playing ESPs, VEPs, and SPs as ESPs.[23][24] 

Psychological safety should also be a consideration when choosing among the groups of ESPs available for use, with consideration for both the psychological safety of learners and the ESPs themselves.  Emotionally charged simulations, such as breaking bad news, may require the use of specially trained SPs as ESPs.[25][26][22] Educators will have to choose among what is available at their institution. Not all simulation centers have access to trained SPs, and some healthcare education programs have very low budgets.  

Clinical Significance

Simulation has become a significant method of education in both nursing and medical schools, as well as in graduate medical education and other training fields in healthcare. Trainers owe it to our learners to execute top-notch, gold-standard simulations following all available guidelines on best practice and simulation education theory. Educators must keep current on simulation education literature and continue to advance the field. Answers to questions raised in this publication regarding which is best (role-playing peers, VEPs, or SPs as ESPs) remain unanswered. The answer may, in fact, be: it depends on learning objectives, access to SPs, budget concerns, etc. Or answers may be obtained by conducting large-scale multi-institution randomized controlled trials of learners. Given that medical schools spend large amounts of both time and money on medical student OSCEs, perhaps there will be funding made available to drive this important research agenda.  

Enhancing Healthcare Team Outcomes

Simulation is used in all healthcare fields and is an excellent tool to enhance interprofessional teamwork.[27][28][29] Simulation team training has demonstrated improved patient outcomes.[30][31][32][33][34]  The recommendation is for the use of appropriately trained ESPs, be they paid, volunteer, or peers who do role-playing. All ESPs can serve a positive and influential role in interprofessional and team training simulations, and also improve patient-centered care.